Fatty liver disease is a growling public health concern for all of us.  Fatty liver disease develops in patients with truncal obesity, type II diabetes, insulin resistance, high blood pressure, elevated cholesterol, and triglycerides, and low thyroid function.  Considering the number of American United States with obesity, fatty liver disease is a growling public health problem that we all face, especially those of us in liver disease and liver transplantation. 

A number of patients with fatty liver disease will progress to cirrhosis over time.  This cirrhosis is unrelated to chronic alcohol use and is thus designated as “nonalcoholic fatty liver disease”.  These patient had developed cirrhosis, developed the same complications related to cirrhosis as thosewith hepatitis C, hepatitis B, and alcohol related liver disease. 

Over the past five years, the number of patient referred for liver transplantation both here in Texas as well as around the country has increased.  It is anticipated that in the next decade, fatty liver disease may be the number one disease leading to the liver transplantation. 

The patients with nonalcoholic fatty liver disease present a number of unique problems to our transplant team.  These individuals have a higher risk of diabetes, and its associated complications including cardiovascular and kidney disease.  This causes increased complications both before and after liver transplant.  Because the majority of these patients are obese, many of which are morbidly obese, they have complications following successful liver transplant with regard to an increased rate of infections especially in the lungs, and more difficulty with the physical rehabilitation that is required after liver transplant. 

Some transplant programs around the United States are performing weight reduction surgery at the time of liver transplant.  Those of us here in Houston are actively engaged with bariatric surgeon and developing a protocol for this. 

Following liver transplant, once the patient is recovered from the immediate liver transplant surgery, we will continue to work with them very closely with regard to controlling their diabetes, high blood pressure, and their elevated cholesterol and triglycerides.  We will also continue to monitor their overall cardiovascular function because of their increase risk of developing a heart attack or stroke. 

One very concerning aspect of transplantation with nonalcoholic fatty liver disease is that following liver transplant, there is a very high frequency of recurrent fatty liver disease in their transplant liver.  This can lead to progressive damage to the transplanted liver as well as the development of recurrent cirrhosis within one to three years after the transplant.  What a shame it is that we care for the patient through a very critical time in their life, getting them transplanted, only to find that have recurrent fatty liver disease and cirrhosis within few years?  Here again, there is a role for weight reduction surgery, most commonly a gastric sleeve procedure, following liver transplant to avoid the problems of recurrent fatty liver disease and cirrhosis in the new liver. 

We will work very closely with these patients with regard to nutritional support and exercise, and personal responsibility in managing these problems.